Social Disparities in the Receipt of Contraceptive Services Among Sexually Experienced Adolescent Females

Abstract

Social disparities in the receipt of contraceptive services were assessed among a sample of 2,031 sexually experienced adolescent females 15 to 18 years of age using secondary data from the National Longitudinal Study of Adolescent Health (Add Health). Findings revealed no social disparities in receipt of contraceptive services; rather, adolescent females who had a parent with less than a high school degree were more likely to receive contraceptive services. Adolescents' individual characteristics, including perceptions of maternal disapproval of sexual activity and use of contraceptives, barriers in access to and use of birth control, health needs, and enabling resources were significantly associated with their receipt of contraceptive services. Neighborhood characteristics were not significantly associated with adolescents' receipt of services in this study.

KEYWORDS:

• Disparities
• adolescent reproductive healthcare
• access to healthcare

Introduction

Healthcare services can play an important role in the prevention of unintentional pregnancies among sexually active adolescents when they include counseling on safer sexual practices and the provision of contraceptives (Brindis, 2002). Adolescents who receive these healthcare services are more knowledgeable about safer sexual behaviors, more consistent contraceptive users, and more likely to use contraceptives that offer greater protection against unintended pregnancy (Boekeloo et al., 1999; Danielson, Marcy, Plunkett, Wiest, & Greenlick, 1990; Kirby, 2002; Orr, Langefeld, Katz, & Caine, 1996; Scher, 2004; Winter & Breckenmaker, 1991). Furthermore, research has revealed that adolescents' improved contraceptive use has contributed significantly to the declines in adolescent pregnancy in the United States over the past decade (Santelli, Lindberg, Finer, & Singh, 2007).

Unfortunately, numerous studies have found that many adolescents, particularly minority and low-income adolescents, have difficulty accessing healthcare services. For example, adolescents from low-income families are more likely to be uninsured (Newacheck, Hung, Park, Brindis, & Irwin, 2003; Shenkman, Youngblade, & Nackashi, 2003), to forgo healthcare due to cost (Newacheck et al., 2003), and to utilize the emergency department as their usual source of care (Wilson & Klein, 2000). Even after controlling for socioeconomic position, African American and Hispanic adolescents are less likely to receive any healthcare (Bartman, Moy, & D'Angelo, 1997; Lieu, Newacheck, & McManus, 1993), including preventive healthcare (Simpson et al., 2005). African American adolescents also are more likely than White adolescents to utilize the emergency department as their usual source of care (Wilson & Klein, 2000) and to forgo healthcare altogether (Ford, Bearman, & Moody, 1999). Although few studies have examined social disparities in adolescents' reproductive healthcare (Elster, Jarosik, VanGeest, & Fleming, 2003), evidence suggests that minority (Fiscus, Ford, & Miller, 2004; Porter & Ku, 2000; Schuster, Bell, Petersen, & Kanouse, 1996) and publicly insured adolescents (Fiscus et al., 2004; Porter & Ku, 2000) may be more likely to receive counseling on safer sexual practices (Porter & Ku, 2000; Schuster et al., 1996) and sexually transmitted infection testing (Fiscus et al., 2004; Porter & Ku, 2000) than White and privately insured adolescents. Reasons for the greater receipt of services in these studies may be that providers target certain populations due to concerns over increased risk (Fiscus et al., 2004; Porter & Ku, 2000).

Previous research has examined the extent to which social disparities in health care exist as well as their potential contributing factors. Although this research has been very influential in advancing our knowledge, attention has been directed to the contribution of individual factors, with very few studies addressing the neighborhood context (Kirby & Kaneda, 2005; Phillips, Morrison, Andersen, & Aday, 1998). Neighborhoods serve as important outlets for the distribution of resources (Subramanian, Chen, Rehkopf, Waterman, & Krieger, 2005), and they may play a role in shaping social disparities in healthcare. The few studies examining this relationship support this argument, as neighborhood poverty was associated with fewer acute and preventive healthcare visits and greater unmet health needs among the individuals residing within these neighborhoods (Brooks-Gunn, Duncan, Klebanov, & Sealand, 1993; Kirby & Kaneda, 2005).

Although research on social disparities in healthcare is burgeoning, studies on disparities among vulnerable populations of adolescents (Phillips et al., 1998), the contribution of the neighborhood context to service receipt (Kirby & Kaneda, 2005; Phillips et al., 1998), and disparities in specialty healthcare services, such as reproductive healthcare, are limited (Elster et al., 2003). Therefore, the purpose of this research was to assess racial, ethnic, and socioeconomic disparities in the receipt of contraceptive services among sexually experienced adolescent females and the contribution of individual and neighborhood characteristics to service receipt and patterns of disparities.

METHODS

Study Design and Data Source

A cross-sectional design was employed for this study, utilizing secondary data from the National Longitudinal Study of Adolescent Health (Add Health) restricted-use data (Udry, 2003). Add Health is a school-based longitudinal study of students in 7th through 12th grade that utilized a multistage, stratified, and clustered sampling design to ensure a nationally representative sample of U.S. schools with respect to region of country, urbanicity, school size, school type, and ethnicity (Harris et al., 2003). Data are available from multiple sources, including adolescents, parents, schools, and communities, which enables the exploration of how multiple contexts influence adolescent health outcomes (Harris et al., 2003).

The variables for this study were derived from wave I of Add Health's restricted-use data set, including the Adolescent In-Home Interview, Parent In-Home Questionnaire, School Administrator Survey, and Contextual Data. Add Health researchers collected the adolescent, parent, and school administrator data between September 1994 and December 1995. The contextual data are derived from a variety of administrative sources, including the Census of Population and Housing, 1990: Summary Tape File 3A and are linked to the adolescent and parent data via participant identification numbers created by the Add Health researchers for each adolescent (Harris et al., 2003).

Sample

The sampling frame (N = 3,165) for this study included non-Hispanic White, non-Hispanic African American, non-Hispanic “other,” and Hispanic females who were between 15 and 18 years of age, reported a history of sexual intercourse, had an available sampling weight, and had a neighborhood identifier to link the contextual and adolescent data. Inclusion criteria imposed on the sampling frame included having never been married, only one child sampled per family, and complete data on all the variables of interest. The final sample size for the study was N = 2,031. The greatest loss of participants was due to missing data (n = 1,074), particularly omissions on parental reports of household income (n = 882) and adolescents' health insurance status (n = 612). The sampling frame contained a total of nine sibling pairs; thus, SAS random sampling procedures were employed so that only one adolescent from the sibling pair was represented in the study. Bivariate analyses indicated the excluded participants were more likely to have been foreign-born, have a parent with less than a high school degree, and have experienced a pregnancy or sexually transmitted infection and they were less likely to have lived in a two-parent household. Consequently, excluded adolescents were more vulnerable, which may have created a conservative bias or underestimation of disparities.

Measures

Dependent variables

The dependent variable—adolescents' receipt of contraceptive services—was based on a single item that asked adolescents whether they ever received a birth control method from a doctor or clinic. The dependent variable was categorical in nature.

Independent variables

Independent variables were selected based on the research literature and several conceptual frameworks related to utilization of healthcare (Aday, 2001; Andersen, 1995). Adolescents' race and ethnicity were categorized as non-Hispanic White, non-Hispanic African American, non-Hispanic “other,” or Hispanic based on adolescents' self-identified racial and ethnic origin. Due to small sample sizes within subgroups, adolescents who reported their racial or ethnic origin to be non-Hispanic and Native American, Asian or Pacific Islander, other, or don't know were grouped together as a non-Hispanic “other” category. A categorical variable for foreign-born status was created based on adolescents' self-report of nativity within or outside the United States.

Adolescent socioeconomic position was measured via the household income to poverty ratio and parental educational attainment. The household income to poverty ratio was based on data related to household size obtained from the Adolescent In-Home Interview, while household income was obtained from the Parent Questionnaire. Household size was calculated based on adolescents' yes or no responses to 20 items regarding the household structure. The rates from the U.S. Census Bureau's 1994 Poverty Threshold, adjusted for family size, were then compared to adolescents' household income based on household size to create a categorical variable that represented the income to poverty ratio (0% to 100%, 101% to 200%, 201% to 300%, 301% to 400%, and more than 400%). Parental education was based on parental reports of their highest level of educational attainment. If parents were missing a response to this item or if they refused to answer, the adolescent's response to an identical question was utilized. Similar imputation of the adolescent's response for missing parental data on education has been used in previous studies that examined Add Health data and reported to consistently correlate with parental responses (Cubbin, Santelli, Brindis, & Braveman, 2005). Parental educational attainment was categorized as less than high school degree or equivalent, high school degree or GED, some college or technical training, and college degree or more.

Family structure was derived from 20 items related to the household structure. Adolescents were asked to list the names of the persons living with them in their household and the nature of their relationship with each of these individuals. A categorical variable was created to represent those adolescents who lived in a two-parent household and those who did not.

Adolescents' attitudes and beliefs about the consequences of adolescent pregnancy, barriers in accessing and using birth control, and maternal disapproval of their sexual activity and use of birth control were measured. Composite indices were created for consequences of adolescent pregnancy and barriers in accessing and using birth control. The composite index for beliefs about the consequences of adolescent pregnancy was based on adolescents' self-reports about how embarrassing a pregnancy would be for them and their families as well as how a pregnancy during their teen years would affect their lives (for example, worst thing to happen, grow up too fast, difficult decisions on whether to have the baby or not). The composite index for beliefs regarding barriers in accessing and using birth control was based on adolescents' self-reports on items related to the cost of contraception, difficulties in obtaining contraception prior to sexual activity, difficulty in getting a partner to use birth control, decreased pleasure with use, and morality issues. Items were coded so that higher scores indicated greater agreement with the item. Exploratory factor analysis and reliability testing via internal consistency were examined. For each composite index, all items loaded onto one factor and all factor loadings were greater than 0.4, which suggested that the items represented one construct. Internal consistencies for the composites were α = .76 for consequences of adolescent pregnancy and α = .79 for barriers in accessing and using birth control.

School health education about adolescent pregnancy and school provision of sexually transmitted infection or family planning services were hypothesized to influence adolescents' receipt of contraceptive services. The receipt of health education about pregnancy was based on adolescents' self-reports and was categorical in nature. School provision of sexually transmitted infection services and family planning services were two items obtained from the School Administrator Survey, which were disaggregated from the level of the school to the level of the individual. The two items were combined to represent one categorical variable: the availability of reproductive healthcare services on site at the school. Thus, if one or more of these services were offered on site at school, adolescents were classified as “yes” to attending a school where these services were offered.

Several enabling resources that may impact adolescents' access to reproductive healthcare services were analyzed, including receipt of a routine physical in the past year, availability of health insurance, and adolescents' obtainment of a driver's license. All three variables were categorical in nature. Adolescents' receipt of a routine physical and driver's license status were based on adolescents' self-report, while insurance status was based on parental report.

Several variables describing the characteristics of adolescents' residential neighborhoods were included. This study conceptually defined the neighborhood as a spatial unit of residence and operationalized the neighborhood as the census tract of residence. Census tracts are frequently considered proxies for neighborhoods in the research literature (Leventhal & Brooks-Gunn, 2000), and their boundaries are used by governments for the allocation of resources (Subramanian et al., 2005). Neighborhood poverty was defined as those census tracts in which 20% or more of the adult residents lived below poverty level, while neighborhoods with low levels of education were defined as those census tracts in which 25% or more of adults older than 25 had less than a high school degree (Krieger, Waterman, Chen, Rehkopf, & Subramanian, n.d.). Categorical variables were created to represent the status of census tracts as either above or below these thresholds. Urbanicity was measured as a categorical variable to indicate whether adolescents lived in an urban or rural census tract, as differential access to health care may occur between these areas (U.S. Dept. Health and Human Services [USDHHS], 2005). Last, a categorical variable was created to represent low levels of female employment, which was defined as fewer than 25% of the women 16 years of age and older in the census tract working full-time for at least 48 weeks of the year. Young women who resided in neighborhoods in which low proportions of women worked may have perceived fewer employment opportunities or had fewer positive female role models available, which in turn may have influenced their reproductive health behaviors (Cubbin et al., 2005).

Statistical Analysis

Since individual adolescents are nested within neighborhoods, one of the intentions of this study was to examine the variation in adolescents' receipt of contraceptive services across neighborhoods. However, preliminary analysis using hierarchical generalized linear modeling revealed no significant variation. In the analyses reported here, characteristics of the neighborhood context are modeled contextually; that is, neighborhood characteristics are disaggregated and modeled at the individual level of analysis, with the result that only individual variability is examined (Diez-Roux, 2003).

All subsequent analyses were conducted using SAS statistical software, version 9.1 (SAS Institute, Cary, NC) and SAS-callable SUDAAN statistical software, version 9.0 (Research Triangle Institute, Research Triangle Park, NC). Sampling weights were utilized with all analyses. Multicollinearity was assessed and findings revealed no significant correlation between the variables. Descriptive analyses were examined on all variables to better understand the characteristics of the adolescents in this study. Unadjusted and adjusted odd ratios were calculated via logistic regression analyses to examine (1) the associations between adolescents' race, ethnicity, and socioeconomic position and their receipt of contraceptive services to better understand the extent to which social disparities in contraceptive services existed and (2) the associations between adolescents' individual and neighborhood characteristics and their receipt of contraceptive services to better understand their contribution to service receipt. The level of statistical significance for all analyses was p < .05.

RESULTS

Descriptive Analyses

The study sample comprised 2,031 sexually experienced adolescent females. Approximately 49% of the adolescent females reported that they received contraceptives from a healthcare provider at least once in their lifetimes. Table 1 presents the characteristics of the adolescent females in this study.

Logistic Regression Analyses

The findings revealed no racial, ethnic, or socioeconomic disparities in the receipt of contraceptive services. In contrast, in both unadjusted and adjusted models, adolescent females whose mother had less than a high school degree were more likely to have received contraceptive services than adolescent females whose mother had a college degree or more (adjusted odds ratio [AOR] = 1.70; 95% confidence interval [CI] = 1.05–2.76). In the unadjusted model, non-Hispanic African American adolescent females had greater odds of having ever received contraceptive services than non-Hispanic White adolescent females, but the association was nonsignificant in the adjusted model. Adolescents' attitudes and beliefs were significantly associated with their receipt of contraceptive services in unadjusted and adjusted models. Specifically, the more adolescents perceived their mother would disprove of their sexual activity (AOR = 0.73; 95% CI = 0.62–0.87) or use of birth control (AOR = 0.76; 95% CI = 0.67–0.86), the less likely they were to ever have received contraceptive services. Additionally, adolescent females who reported more barriers in accessing and using birth control were less likely to have ever received contraceptive services compared to those who reported fewer barriers (AOR = 0.67; 95% CI = 0.53–0.85).

TABLE 1 Characteristics of the Adolescent Females in the Total Sample: National Longitudinal Study of Adolescent Health, 1994–1995 (N = 2,031)

Adolescent characteristics	% (SE)
Race and ethnicity
Non-Hispanic White	69.3 (3.9)
Non-Hispanic Black	20.0 (3.6)
Non-Hispanic “other”	2.6 (0.7)
Hispanic/Latina	8.1 (1.6)
Income to poverty ratio
0%–100%	21.2 (2.2)
101%–200%	22.3 (1.3)
201%–300%	21.4 (1.7)
301%–400%	13.1 (1.2)
401% and higher	22.0 (1.7)
Parental education
Less than high school	16.4 (1.8)
High school degree	34.0 (1.7)
Some college or technical training	31.0 (1.7)
College degree or more	18.6 (1.6)
Health insurance
Yes	87.5 (1.1)
No	12.5 (1.1)
Driver's license
Yes	50.7 (2.6)
No	49.3 (2.6)
Two-parent household
Yes	59.9 (2.2)
No	40.1 (2.2)
Receipt of routine physical
Yes	65.9 (1.8)
No	34.1 (1.8)
Received school sex education
Yes	90.0 (1.1)
No	10.0 (1.1)
School provides reproductive healthcare services
Yes	6.3 (2.9)
No	93.7 (2.9)
Sexually transmitted infection history
Yes	6.7 (0.7)
No	93.3 (0.7)
Pregnancy history
Yes	16.4 (1.4)
No	83.6 (1.4)
Lived in poor neighborhood
Yes	24.3 (4.2)
No	75.7 (4.2)
Lived in lower-educated neighborhood
Yes	57.2 (4.8)
No	42.8 (4.8)
Lived in neighborhood with low % of employed women
Yes	33.4 (4.5)
No	66.6 (4.5)
Lived in urban neighborhood
Yes	51.7 (5.4)
No	48.3 (5.4)
Note. Sample size unweighted, proportions weighted.

TABLE 2 Unadjusted and Adjusted Logistic Regression Analyses on the Associations Between Adolescent Characteristics and Adolescent Receipt of Contraceptive Services: National Longitudinal Study of Adolescent Health, 1994–1995 (N = 2,031)

Adolescent characteristics	Unadjusted model OR (95% CI)	Adjusted model OR (95% CI)
Race
Hispanic	0.80 (0.53–1.20)	1.04 (0.62–1.75)
Non-Hispanic Black	1.45 (1.08–1.94)*	1.32 (0.87–1.99)
Non-Hispanic “other”	1.07 (0.60–1.91)	1.57 (0.82–3.01)
Non-Hispanic White (reference)	1.00	1.00
Foreign-born	0.80 (0.34–1.91)	1.17 (0.46–2.96)
Income to poverty ratio
0%–100%	1.15 (0.84–1.59)	1.13 (0.68–1.87)
101%–200%	0.96 (0.68–1.35)	0.88 (0.58–1.35)
201%–300%	0.82 (0.59–1.14)	0.76 (0.51–1.14)
301%–400%	0.84 (0.58–1.23)	0.86 (0.56–1.32)
400% or more (reference)	1.00	1.00
Parental education
Less than high school	1.49 (1.04–2.12)*	1.70 (1.05–2.76)*
High school degree or GED	1.23 (0.90–1.68)	1.26 (0.89–1.78)
Some college/technical	1.17 (0.83–1.66)	1.16 (0.79–1.72)
College degree or more (reference)	1.00	1.00
Pregnancy undesirable	0.73 (0.64–0.83)*	0.88 (0.76–1.03)
Barriers to birth control	0.71 (0.59–0.85)*	0.67 (0.53–0.85)*
Mom disapprove of sex	0.61 (0.53–0.70)*	0.73 (0.62–0.87)*
Mom disapprove of birth control	0.64 (0.58–0.70)*	0.76 (0.67–0.86)*
Health insurance	1.17 (0.81–1.69)	1.40 (0.94–2.08)
Received routine physical past year	2.13 (1.68–2.72)*	1.84 (1.41–2.40)*
Driver's license	1.61 (1.29–2.00)*	1.67 (1.24–2.24)*
Two-parent household	0.70 (0.56–0.86)*	0.81 (0.60–1.10)
Received school sex education	1.62 (1.05–2.50)*	1.45 (0.93–2.28)
School provides reproductive healthcare	1.09 (0.70–1.71)	0.99 (0.52–1.86)
Sexually transmitted infection history	4.71 (2.76–8.04)*	3.96 (2.02–7.78)*
Pregnancy history	2.36 (1.73–3.22)*	1.79 (1.25–2.57)*
Neighborhood poverty >20%	1.01 (0.76–1.34)	0.86 (0.51–1.45)
Neighborhood low education >25%	1.16 (0.91–1.47)	1.10 (0.82–1.48)
Neighborhood female employment	0.88 (0.67–1.15)	0.83 (0.57–1.22)
Neighborhood in urban area	0.87 (0.69–1.10)	0.81 (0.59–1.09)
Note. OR = odds ratio; CI = confidence interval.Sample size unweighted, OR and CI weighted.
Source. Harris et al. (2003) and Udry (2003).

Health needs were strongly associated with adolescents' receipt of contraceptive services in both the unadjusted and adjusted models. For example, adolescents with a previous sexually transmitted infection diagnosis (AOR = 3.96; 95% CI = 2.02–7.78) or pregnancy (AOR = 1.79; 95% CI = 1.25–2.57) were significantly more likely to have ever received contraceptive services than adolescents females without these health needs.

Enabling resources also played a role in adolescents' receipt of contraceptive services. Adolescent females who had a driver's license (AOR = 1.67; 95% CI = 1.24–2.24) or who received a routine physical in the previous year (AOR = 1.84; 95% CI = 1.41–2.40) were more likely to have ever received contraceptive services than female adolescents who did not have these resources. Health insurance was not significantly associated with adolescents' receipt of contraceptive services in unadjusted or adjusted models, while receipt of sex education about adolescent pregnancy was positively associated with receipt of contraceptive services, but in unadjusted models only. Schools' provision of reproductive healthcare services was not significantly associated with adolescents' receipt of contraceptive services in unadjusted or adjusted models. Contrary to hypotheses, neighborhood characteristics were not associated with adolescents' receipt of contraceptive services in unadjusted or adjusted models.

DISCUSSION

The findings revealed no racial, ethnic, or socioeconomic disparities in adolescent females' receipt of contraceptive services. In contrast, adolescent females who had a mother with less than a high school degree were more likely to have received services than those adolescents who had a mother with a college degree or more. This finding is in accordance with previous studies in which vulnerable populations were more likely to receive reproductive healthcare services (Fiscus et al., 2004; Porter & Ku, 2000; Schuster et al., 1996). Although the lack of social disparities in contraceptive services revealed in this study is encouraging, several factors may play a role in the receipt of reproductive services among vulnerable populations. First, adolescent pregnancy and sexually transmitted infection were highly associated with the receipt of contraceptive services among the adolescents in this study. Since minority and low-income adolescents are more likely to experience an unintentional pregnancy and sexually transmitted infection (Abma, Martinez, Mosher, & Dawson, 2004; Centers for Disease Control and Prevention, [CDC], 2006; Finer & Henshaw, 2006), potential social disparities in the reproductive health of the adolescent females in this study may have contributed to their receipt of services. Second, widespread educational campaigns have increased providers' awareness about racial and ethnic disparities in reproductive health and reproductive health screening; thus, providers may be more likely to offer contraceptive services to adolescents they believe are in need (Mosher, Martinez, Chandra, Abma, & Wilson, 2004; USDHHS, 2000).

The most robust associations we found in this study with adolescents' receipt of contraceptive services were their individual perceptions about contraceptive barriers, concerns over maternal disapproval of their sexual behaviors, and their access to certain enabling resources. For example, adolescent females who perceived more barriers in accessing and using birth control (for example, cost, accessibility, difficulty in getting a partner to use birth control, and decreased pleasure with use) and those who were concerned their mother would disapprove of their sexual activity or their use of birth control were less likely to report they had received contraceptive services. These findings are consistent with evidence from previous research (Cheng, Savageau, Sattler, & DeWitt, 1993; Jones, Purcell, Singh, & Finer, 2005; Manlove, Ryan, & Franzetta, 2007; Reddy, Fleming, & Swain, 2002; Scher, 2004) and highlight the complexities that many adolescent females face in accessing and using contraception. Adolescent females who had access to certain enabling resources, such as a driver's license or receipt of a routine physical in the past year, were more likely to receive contraceptive services. Independent transportation to a provider's office or clinic facilitates access to services for those adolescents who desire confidentiality and also for those adolescents who have working parents for whom taking time off for preventive healthcare appointments may be difficult. Surprisingly, health insurance was not a significant factor in the receipt of contraceptive services in unadjusted or adjusted models. Reasons for this may be the lack of birth control coverage by some insurance companies or perhaps adolescents' concerns over confidentiality.

Contrary to hypotheses, adolescents' receipt of services did not statistically vary across neighborhoods, nor were there significant associations between the characteristics of adolescents' neighborhoods and their receipt of contraceptive services. However, this study was cross-sectional in nature and longitudinal research in this area is needed, as clinic availability, quality of services, and adolescents' confidentiality concerns may vary over time and place and influence adolescents' access to and use of services.

Several limitations to this study may have impacted the findings. First, approximately 30% of the sampling frame had missing data due primarily to missingness or refusals on items related to household income and health insurance. Analysis revealed that the missing data on these two items were not missing at random, meaning that they were correlated with the dependent variable, a condition known as systematic missingness (Allison, 2001). Although imputation measures are commonly recommended for systematic missingness to prevent biased estimates, simulation studies have revealed these procedures may also be biased (Kromrey & Hines, 1994). Results of these studies found that listwise deletion provided accurate estimates when up to 30% of the data were missing (Kromrey & Hines, 1994); this method was employed in this study. Further methodological analyses examining the best practices for handling missing data are needed, particularly for health disparities research, as missing income data are a common problem.

Second, the data for this study were collected in 1994 and 1995 and changes in the healthcare system have occurred. Unfortunately, funding for family planning clinics has actually decreased between 1995 and 2003 due to cuts in Medicaid and fewer clients affording to pay full cost for their services (Lindberg, Frost, Sten, & Dailard, 2006). Consequently, the number of family planning clinics offering free services for adolescents decreased from 66% in 1999 to 44% in 2003 (Lindberg et al., 2006). Thus, the findings from this study are particularly relevant today, as they revealed that adolescents who reported barriers in accessing and using birth control were less likely to have received contraceptives. Furthermore, the availability of low-cost services may be declining in some communities more than others; thus, as mentioned previously, future research should consider how geographic variation in the availability of services impacts adolescents' access to and use of services.

POLICY IMPLICATIONS

The findings from this study underscore the need to maintain avenues to confidential and comprehensive contraceptive services for adolescents. Currently, federal legislation requires all family planning clinics that receive Title X funding to provide confidential contraceptive services to minors (Alan Guttmacher Institute [AGI], 2010; Jones et al., 2005). However, states have enacted legislation that may reduce adolescents' access to confidential contraceptive services depending on where they receive their care. To date, 21 states have passed legislation that enables all minors 12 years and older to consent to contraceptive services; 25 states only allow minors to consent under specific circumstances, such as a previous pregnancy or childbirth, if married, specific health concerns, or at a certain age; and four states have enacted no legislation on the issue (AGI, 2010). Two states have laws that prohibit the use of public funds to provide adolescents with confidential contraceptive services and seven states stipulate that a provider is not required to notify a parent that the minor is seeking contraceptive services, but he or she may do so under the law if he or she chooses (AGI, 2010). Further research on the impact of state laws regarding adolescents' access to confidential services on teen pregnancy rates are needed, as one Illinois county observed an increase in its adolescent pregnancy rate after enacting a mandatory parental notification law (Zavodny, 2004). Maintaining the availability of confidential contraceptive services for adolescents is vital to prevent a backslide in our progress to reduce rates of unintended pregnancies, as many adolescents are unable or perceive they are unable to involve their parents in issues surrounding their sexual health.

Primary care providers and public health professionals can also facilitate adolescents' access to contraceptive services. Specifically, clinical practice guidelines recommend that all adolescents receive safer sex counseling at their routine physicals (American Academy of Pediatrics, 2000); these visits offer adolescents and providers an opportunity to discuss adolescents' sexuality, their need for contraception, the different methods available and their correct usage, and ways to enhance their communication about sexuality and contraception with their parents as well as with their sexual partner(s). Furthermore, public health programs that include information on where adolescents can access free or low-cost contraceptives are vital, as are pregnancy prevention programs that focus on partner communication regarding safer sex, myths related to contraceptive use, and parent-teen communication about sexual health issues.

CONCLUSIONS

Healthy People 2010 declared the promotion of responsible sexual behavior a priority for improving the health of adolescents within the United States (USDHHS, 2000). In order to achieve this goal, adolescents need to be assured access to confidential contraceptive services and provided skills on how to negotiate contraceptive use with their partner. The financial difficulties threatening the viability of many family planning clinics and their ability to offer free or low-cost services to adolescents (Lindberg et al., 2006) are alarming since the declines in adolescent pregnancy over the past decade are due primarily to their improved contraceptive use (Santelli et al., 2007). Free or low-cost confidential services are vital for all adolescents, but particularly for socially disadvantaged adolescents as they also experience disproportionately higher rates of unintended pregnancy, sexually transmitted infection and HIV infection (Abma et al., 2004; CDC, 2006; Finer & Henshaw, 2006). It is imperative that we address the structural and social barriers that adolescents face in accessing and utilizing contraceptives in order to promote their sexual health and well-being.

Notes

This research uses data from Add Health, a program project designed by J. Richard Udry, Peter S. Bearman, and Kathleen Mullan Harris, and funded by grant P01-HD31921 from the National Institute of Child Health and Human Development, with cooperative funding from 17 other agencies. Special acknowledgment is due Ronald R. Rindfuss and Barbara Entwisle for assistance in the original design. Persons interested in obtaining data files from Add Health should contact Add Health, Carolina Population Center, 123 West Franklin Street, Chapel Hill, NC 27516-2524, USA. [email protected]

*p ≤ .05.